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Hookah smoking is no safer than cigarette smoking. If you read no further, that is the take-home message for this blog -- no matter what you may have heard or read, the scientific evidence is clear that hookah smoking is not a safe alternative to smoking cigarettes.

Countering the widely-held, although mistaken, belief that hookah smoking is safer than cigarette smoking is important, so let's take a step back and consider what hookah is, learn about its history and current popularity, and then look at the facts about the scientific evidence regarding its effects on health.

An ancient practice

Hookah is a bowl-shaped device with a tubular pipe. It also may be called waterpipe, shisha or hubble-bubble. Charcoal-heated air is passed through a tobacco mixture and then through a water-filled chamber and, ultimately, through the pipe for the user to inhale. Though it sounds complicated, a hookah is an ingenious and relatively simple way of delivering tobacco smoke. (see photo, on left)

The practice of hookah smoking goes back nearly 500 years. It most likely began in India after Columbus brought back the first tobacco plants and seeds from the Americas, where tobacco had been in use for centuries.

Of course, they didn't have the modern additives that make tobacco smoke smoother today, so Indian tobacco users experimented with passing the smoke through heated water bowls to make the smoke easier to inhale. The practice moved westward quite quickly, and within another century, the modern version of the hookah was in use throughout the Middle East, where it was often used in groups and became a social activity.

An exception to clean air rules

Currently, hookah is used in many countries around the world, and people seem to be accepting and embracing it quickly. In the U.S., data indicate that it's usually used among young adults, with several studies indicating that about 10%-25% of them used hookah in the past month. Unfortunately, teens also have begun to take up the practice.

Hookah bars have also popped up, many of them in college towns (such as Palo Alto, California, in photo on right), in order to take advantage of the built-in young adult population. Since there has been a lot of confusion about the health effects of hookah, some municipalities -- even those that have strict regulations regarding cigarette smoking - have made an exception for hookah bars. This is because the bar owners have successfully argued that hookah smoking is substantially different than cigarette smoking, both in how it's inhaled and how much secondhand smoke there is.

However, hookah smoking is very little different than cigarette smoking. The fruit, honey, and other flavorings that are used in hookah tobacco, as well its moistness due to being passed through water, and its function as a relaxing social activity, all go to mask the fact that what hookah users and those around them are inhaling is tobacco smoke -- with all of the health dangers that accompany it.

Proven health risks of hookah

As hookah smoking has taken off across the world, there's been more research into its health effects.

Hookah smoke, like cigarette smoke:

contains significant amounts of cancer-causing ingredients, such as arsenic, cobalt, chromium, and lead;

has the same addictive properties, which can lead a hookah user to begin using cigarettes, or becoming a dual user of hookah and cigarettes.

Additionally, hookah use has several uniquely unhealthy qualities:

Hookah users may inhale more smoke than cigarette smokers, because hookah sessions often last an hour or more, during which hookah users will inhale not only the smoke from the hookah itself but also that of the others with whom they are smoking;

Unlike cigarettes, hookah smoke may also contain charcoal or wood cinder combustion products, which can increase cancer- and heart disease-causing agents in the smoke; and

Sharing the hookah's waterpipe can increase the risk of contracting a communicable disease, such as tuberculosis, hepatitis, or meningitis.

So, the bottom line is that, appearances and popular beliefs to the contrary, hookah smoking offers no refuge from the dangers of cigarette smoking. Despite the relaxing social atmosphere in which hookah is used, its pleasant flavorings, and its smoother taste, it is a devil in disguise and should not only be avoided, but subject to the same laws and regulations as cigarette smoking.

Hi, John, Tom had this to say to answer your question:
The tobacco used in shisha smoking is no different than the tobacco used in cigarette smoking, except for the flavorings that are added to shisha. Both lead and arsenic are among the heavy metals that occur naturally in tobacco leaves and, when burned and then inhaled, contribute to the ill effects from tobacco use. Both the CDC and the U.S. Surgeon General have determined that lead and arsenic (among more than 7000 constituents of tobacco) are present in all tobacco (including that used in shisha smoking) and should be avoided. An article specific to the presence of lead and arsenic in tobacco is linked below.
http://www.ncbi.nlm.nih.gov/pubmed/22571020

The following quotes are from smokefree.gov, the Department of Health and Human Services website created by the National Cancer Institute.

Some hookahs have labels stating that they include "0% tar". Is this accurate information?

No, this is deceptive. No tobacco contains tar before it is smoked; tar is produced by burning tobacco. It should be noted that a single standard hookah smoking session is associated with 46.7 times the amount of tar relative to a single cigarette [17].

Is hookah smoking addictive?

Yes. Tobacco is used in the hookah and contains nicotine. Hookah smokers are therefore exposed to the addictive substance, nicotine [19]. The amount of tobacco smoked in one head of hookah has the nicotine content contained in 70 regular cigarettes [20].

This is completely false info. The main article includes no references, and the references you are sighting in your comments are poorly researched articles. The truth is that there has yet to be any substantial research revolving around hookahs one way or another. Common sense would say that anything you inhale isn't good for you. But these gross misproportions are entirely hyperbolic. Talk to any REAL doctor, and they will tell you that processing tobacco equivalent to 70 cigarettes in one session would cause IMMEDIATE problems. This is just a bogus article.

Hi, Anthony, we do not typically include references directly in the blog for space and readability issues, but we of course do have them handy for each statistic or assertion we make. For what specifically are you interested in seeing references? I can supply them to you.

Can you please tell me if tobacco-free Hoookah -- Beamer is the brand my son is using -- is "safe"? It does use coal for burning so I could see the carbon monoxide being a health risk. Can you refer me to any studies about this? I only saw one journal article out of Canada in my search so far. Has Beamer been studied independently by medical professionals not affiliated with the company? Thank you in advance for your insights and expertise.

Hi, Kathleen, Dr. Glynn has the following answer for you: "I haven't seen much on non-tobacco hookah (sometimes called herbal hookah), probably because it is a relatively new phenomenon, at least in the U.S., in response to concerns about tobacco-based hookah. And I have seen nothing on product-specific research (e.g. Beamer, a molasses product). But you're right about the concerns regarding using non-tobacco hookah. Here is something from Columbia Univ. which says it better than I can:

"Hookah smoking has its own demon — combusted charcoal — which carries health risks even when non-tobacco shisha is used. When charcoal is burned to create the hookah effect, it releases chemicals in the process, namely carbon monoxide (CO) and polyaromatic hydrocarbons (PAHs). In addition to inhaling byproducts of the shisha, waterpipe smokers also inhale fairly large quantities of these combustion-related toxins — a hidden health risk associated with hookah smoking, even for non-tobacco shisha.

One recent study found that in a typical hookah smoking session, participants inhaled more carbon monoxide than someone who smokes a pack or more a day of conventional cigarettes. While hookah tobacco (or non-tobacco shisha) can be bought with very trace amounts of nicotine, or even be tobacco-free, most hookah devices are solely designed for charcoal burning to be the mechanism of inhalation. Tobacco tends to burn more slowly than many of the fruit and molasses contents in non-tobacco shishas. And so, while it is true that you aren't inhaling tobacco smoke, the sustained burning of the charcoal carries the risk of extended exposure to these chemicals. Even at low levels of exposure, both CO and PAH have corrosive and carcinogenic properties, just like most combustion by-products." (end of quote)

Now, that said, if your son is smoking non-tobacco hookah every couple of weeks, there probably isn't a whole lot of health danger for him, unless it became a lifelong habit. The more immediate danger would be dirty pipes, which can spread all sorts of nasty diseases."

Dr. Glynn, when used properly the tobacco does not combust. It is whetted down with glycerine. The hookah is a vaporizer. The difference is tobacco burns at temp's above 1600 degrees. The hookah only raises the tobacco to about 400 degrees. That said, most hookahs are misused but you never burn the tobacco in a hookah. You boil it and vaporize the nicotine and other essential oils.

What about the 'safety" of the trendy e-hookah pens that are being sold? I read the container of one and all I can tell from it is that 18+ users are required and it contains 6 mg of nicotine. I'm only worried that it doesn't tell me more, because I have seen some underage users in some high schools. I'm having doubts on the reliability of this "water vaporized" smoking substitute being used by young, non-smoking teens.

Firstly thank you so much for the information! I shall share it with my friends... with that said, I was first introduced to hookah through some persian friends five years ago. I'm definitely aware of how harmful tobacco is but I like the aesthetic qualities of smoking from a hookah. There's nothing like sitting outside under the stars with your friends around a warm hookah. However, I want to be able to do this without worrying about so many negative effects on my health. I have begun by making my own "shisha" There are a number of ways to do this. I like to use the dried peel shavings from lemons and limes mixed with a tablespoon on orange honey. I don't get headaches from this recipe like i normally do from commercial shisha. Now if i were to eliminate the charcoal and use an electric one that heats the shisha would the carbon monoxide and PAHs be eliminated?

I was wondering what you could tell me about these nicotine free water vapor hookah pens. Wouldn't those be better for you since not only do they not have nicotine, but they also avoid the health issues of the charcoal or wood?

This is a very lacking article. I understand the concerns about carbon monoxide but this article is not very well researched. For years they have offered tobacco-free shisha (the stuff you smoke in a hookah) that are based from herbs, tea, etc. Whoever's to say you've never heard of "tobacco-free hookah" ... that is an ill-researched, uninformed statement. There are many brands to be had that are safe, non-addictive alternatives. That being said, I don't smoke, I am just informed. Before publishing an article like this keep in mind about the facts you are telling because there are a lot of key pieces of info missing so you can sway people's opinions. This is very ill-executed rhetoric. Re-earn that PhD

Look. All of you people are saying hookah pens aren't harmless. You have to be lying to yourself. Nicotine is nicotine. Your still inhaling it. People in middle school are using them. Think about their futures. Lung cancer? This isn't harmless. You can all keep trying to convince yourself hookah pens aren't harmful, it doesn't matter to me because its not me. But when you start having breathing problems, it won't be anyone's problem. In all honesty, they aren't cool, trendy, or anything that means cool. If anything, it's the complete opposite.

I would like to point out the epic fail in this article, as iterated by a previous commenter. You claim that all tobacco produces tar when it is burned and that hookah produces 47 times the smoke of a cigarette... this PROVES you are completely misusing the hookah for your studies, which means ALL your results are completely irrelevant and misleading. Hookah tobacco is supposed to be "baked" or vaporized, NOT burned... if you are burning the tobacco you are doing it wrong!! And when I picture a group of scientists surrounding a hookah, I definitely picture them having no clue what to do. The tobacco must be packed to the appropriate level, the right heat must be kept on it, and if it starts to become harsh or "burnt", the heat must be immediately managed to remedy the problem and get the hookah back on track.

The fact that the controls for these experiments are never published all tell me this is a bunch of bologna to victimize even a less harmful form of tobacco. Your claim that hookah has the same addictive properties that can cause someone to become a cigarette smoker is not only a completely unsubstantiated claim, but its completely laughable! I have been smoking hookah for 5 years... in these 5 years, I quit for 1 year because my wife did not like the fact that I smoked it. Prior to that, I used hookah daily. I experienced absolutely no physical withdrawal symptoms that is associated with nicotine addiction. The only reason I started back into it is because I applied to work at a hookah lounge for extra income. I have never seen anybody "crave" hookah, yet I have seen people needing to take breaks for hookah to go smoke their cigarettes. Again, cigarettes are a harsh, poor-tasting form of tobacco, and hookah is a sweet, smooth form... complete opposites. This is why your claim is laughable. I know this will not elicit a response, but I hope others will see this and start to question the propaganda perpetuated by anti-tobacco lobbyists.

I realize that hookah is not good for you. However, if you were to use herbal molasses (which is just sugar cane), and a charcoal free electronic ceramic shisha bowl, would that make hookah safe? There would be no inhaling of tobacco biproducts, or burned charcoal biproducts. I am merely curious.

Many / most hookahs nowadays are not filled with tobacco, contain no nicotine, and the users do not inhale.

Just like Charcoal BBQ grilling or burning incense, you may experience some non-tobacco ambient smoke, but Hookahs filled with rose petals, herbs and non-tobacco fillers and not inhaled are as different from smoking cigarettes as is burning incense in the home.

I don't smoke Hookah or anything else. I don't sell, but or even participate in this activity, nor do I believe cigarettes should still legal.